How the monsoon fuels India’s drug-resistant infections surge

As the monsoon sweeps across India, it brings relief from the heat as well as a surge in vector-borne and water-borne infectious diseases, straining India's overburdened healthcare systems. It also leads to widespread (mis)use of antimicrobial drugs, worsening the growing threat of antimicrobial resistance (AMR)—a phenomenon whereby microbes evolve to resist life-saving medicines. When antimicrobials are used incorrectly, like consuming antibiotics (which are meant to target bacteria) for viral infections or not completing the prescribed course, they may not kill all harmful microbes. The exposure of the surviving microbes to the medicines enables them to develop traits that help them resist future treatment with the same medicine, making infections harder and more expensive to cure.

Let’s examine how monsoon amplifies the risk of AMR. Floods and waterlogging that act as sites for vector breeding and water contamination cause community-wide outbreaks of diarrhoea, leptospirosis, malaria, chikungunya, and dengue. Overcrowded hospitals deprive clinicians of the luxury of examining patients thoroughly, thereby prompting presumptive antimicrobial drug use without diagnostic confirmation. Prescriptions also often involve non-specific broad-spectrum antibiotics that target multiple bacteria, including harmless ones. This disrupts the body’s microbial balance and allows resistant microbes to thrive. Diagnostic tests help ensure accurate treatment by identifying the specific microbe causing the infection, allowing healthcare providers to prescribe the targeted narrow-spectrum antimicrobial medicine, thereby avoiding unnecessary or incorrect drug use. However, the cost of diagnostic tests (approximately Rs 800-Rs 5,500) is much more expensive than a course of common antibiotics, making it unaffordable for many patients. For those who can afford them, the turnaround time for results is often too long, delaying treatment and discouraging reliance on testing.

Further, financial strain leads households, especially poorer ones, to share prescriptions or medicines when multiple family members fall ill, often from infections caused by different microbes. They also tend to turn to private chemists for guesswork prescriptions. This creates a vicious cycle of trial-and-error prescribing, fuelling AMR and relapse of drug-resistant infections.

Treating a drug-resistant infection costs significantly more than treating a non-resistant one. An Indian cohort study by Kadam et al in 2024 across eight hospitals found the median cost for drug-resistant bloodstream infections was around Rs 17,200 – 82% higher than the approximately Rs 9,400 for non-resistant infections. Even in government hospitals, treating drug-resistant infections costs 40.4% more than treating non-resistant infections.

When patients pay most healthcare costs themselves, known as out-of-pocket (OOP) spending, they are more likely to use antimicrobial drugs in ways that worsen the spread of AMR. A global study including India, by Alsan et al published in 2015, found that for every 10% rise in OOP health spending, drug-resistant infections rose by over 3%. The problem worsens when even government hospitals charge for essential medicines.

In India, OOP spending makes up 70% of health expenditure, with medicines being the biggest expense. Poorer households, often forced to borrow to pay hospital bills, are the worst affected. Many delay or skip treatment, rely on informal providers and self-medication, or buy cheaper, incomplete courses of medicine from local pharmacies without prescriptions, bypassing formal care – these practices inevitably fuel AMR and deepen financial distress.

Although flagship schemes like Ayushman Bharat aim to offer financial protection, they rarely cover outpatient medicines or diagnostic tests – services that play a key role in preventing AMR by accurately identifying the cause of infection and ensuring the right antimicrobial is used only when needed. To address this, the government must expand access to free and rapid diagnostics, especially during the monsoon, in public health facilities. Though not always cost-effective at the individual level, public provision of testing helps prevent inappropriate prescription, making it a smart population-level investment. Copayments for essential antimicrobial drugs should be eliminated, making them free of cost, and subsidies must be introduced for second-line treatments when AMR renders cheaper medicines ineffective. Seasonal surveillance must also be strengthened to track AMR and guide effective responses.

People, too, must act responsibly. Seeking diagnostic confirmation before starting treatment, avoiding self-medication, and completing the full course of prescribed antimicrobial drugs are crucial individual actions. If both public systems and private behaviour align, India can stop the monsoon from becoming a flashpoint in contributing to the growing menace of AMR.

(The writer is an adviser on AMR to the Government of Karnataka and Professor of Practice, St Joseph’s University, Bengaluru)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.